Nowhere is this statement more pertinent than in health care. The past decade has seen tremendous changes in all aspects of health care, particularly in reimbursement.In addition to the introduction and increasing dominance of managed care, these changes have included an ever-increasing degree of sophisticated, highly technological and expensive diagnostic and treatment procedures.
Along with this increasing reliance on technology, we have witnessed a rise in the credibility and utilization of alternative therapies, including chiropractic. As an aside, if you remember the mid-80s and the book Megatrends (Naismitt, 1984), one of the trends the author discussed was an increasing need for personal interaction or "soft-touch" as society became more technologically oriented and "high-tech." It would appear that his predictions were accurate in this regard.
While the use of manipulation, mobilization, massage and exercise have been used for thousands of years, only recently has there been enough interest in the scientific community to investigate the merit of many of these procedures. It has been stated that, "There is now enough evidence to justify the continued use of many of these procedures for selected patients and, while they are not a panacea, they represent an effective, low-tech, natural way of relieving pain and suffering that is essentially free from the negative effects of long-term medication use. For many patients, they offer hope and allow a return to active and productive lives." (Haldeman and Hooper, 1999) In particular, spinal manipulative therapy represents perhaps the best example of the legitimization of a controversial modality for the treatment of spinal disorders (Haldeman and Hooper, 1837).
A study recently published in JAMA looked at the use of alternative therapies in the U.S. from 1991 to 1997 (Eisenberg et al, 1997). According to the authors, the use of at least one of 16 alternative therapies during the previous year increased from 33.8% in 1990 to 42.1% in 1997; the probability of visiting an alternative medicine practitioner increased from 36.3% to 46.3%. Extrapolations to the U.S. population suggest a 47.3% increase in visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997. This exceeds total visits to all U.S. primary care physicians.
As one might expect, alternative practitioners were most often seen for chronic conditions like back pain, anxiety, depression and headaches - precisely the types of patients that make up the bulk of many chiropractic practices. In 1997 an estimated 15 million adults took prescription medication concurrently with herbal remedies and/or high-dose vitamins. That represents 18.4% of all prescription users: and means that, nearly one out of every five individuals taking prescription medicine also use some form of alternative care. An interesting side note is that patients who use both traditional and alternative approaches are more likely to inform the alternative practitioner that they are taking medication than to inform their medical practitioner that they are using some form of alternative method.
In spite of the tremendous changes in the reimbursement for health care that occurred during the '90's, the percentage of patients visiting alternative providers and paying entirely out-of-pocket did not change significantly, with only a slight reduction from 64.0% to 58.3%. During the study period, estimated expenditures for alternative medicine services increased 45.2% and were conservatively estimated at $21.2 billion; at least $12.2 billion of this was paid out-of-pocket. This exceeds the 1997 out-of-pocket expenditures for all U.S. hospitalizations. The total 1997 out-of-pocket expenditures relating to alternative therapies was conservatively estimated at $27 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all U.S. physician services.
In response to this somewhat overwhelming interest on the part of the health care consumer, and faced with the increasing use of complementary and alternative medicine, medical schools are finally beginning to educate physicians about these therapies. One hundred and twenty-five medical schools were surveyed in 1997-98 (Wetzel et al., 1998). Seventy-five (64%) respondents reported offering courses in complementary or alternative medicine, or at least including these topics in required courses. Of 123 courses reported, 84 (68%) were stand-alone electives, 38 (31%) were part of required courses, and one (1%) was part of an elective. Common topics for discussion included: chiropractic; acupuncture; homeopathy; herbal therapies; and mind-body techniques.
So what? With the growing acceptance and utilization of alternative approaches to health care, it would appear that the chiropractic profession is poised at the brink of tremendous potential growth. If one looks at the type of conditions for which alternative approaches are sought, and the kinds of conditions that are most problematic in the work place, it should be evident that the need for alternative approaches to health and wellness is increasing. It would appear that chiropractic services would become increasingly necessary in the very near future.
What do we do with this information? I have long been an advocate for chiropractors positioning themselves as experts in the area of back pain, particularly back pain in the work place. While I understand that a segment of the profession has some concern about painting ourselves into a "musculoskeletal box." It has been my contention that this is a large box, and that we have much to offer. However, I was involved in a couple of interesting conversations recently that made me wonder where we are headed. One of the conversations took place in a class I was teaching. I was using some of Dr. Eisenberg's data to explain that there was a positive shift in the use of alternative or complementary medicine. In my mind, this is a good thing. However, several students challenged me on the use of the terms "alternative" and "complementary" when talking about chiropractic. It appeared they were uncomfortable with the idea that chiropractors are considered an alternative. In the second conversation, a group of practitioners was wrestling with the term "complementary" and seemed to take similar offense to the terminology.
I guess I'm confused. For the nearly 30 years that I have been associated with this profession, we have struggled for our place in the health care arena. It appears that we are in a very favorable position, and yet we can't seem to come to terms with this acceptance. We want something more or something different. From my vantage point, it is possible for the chiropractic profession to position itself on the top rung of the "alternative provider" ladder. As I see it, that's a good place to be.
- Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler. RC Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998 Nov 11;280(18):1569-75.
- Haldeman S, Hooper PD, Phillips RB, Scaringe JG, Traina AD. Spinal manipulative therapy. In: Frymoyer JW (ed.) The Adult Spine: Principles and Practice, 2nd ed. Lippincott-Raven, Philadelphia, 1997, pp. 1837-1861.
- Haldeman S, Hooper PD, Mobilization, manipulation, massage and exercise for the relief of musculoskeletal pain. In: Wall PD, Melzack R (ed.) Textbook of Pain, 4th ed., ed. Churchill-Livingstone, Edinburg, 1999, pp. 1399-1418.
- Wetzel MS, Eisenberg DM, Kaptchuk TJ. Courses involving complementary and alternative medicine at US medical schools. JAMA 1998 Sep 2;280(9):784-7.
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